1601006105 LONG CASE

1601006105 long case

Chief complaints:

46 yrs old male patient from bopparam labourer by occupation came to the opd with chief complaints of shortness of breath , bilateral pedal edema and decreased urine output since 1week 

History of presenting illness 

patient was apparently asymptomatic 1week ago and then he developed shortness of breath which was insidious onset gradually progressive (grade 2).
Bilateral pedal edema since 1 week pitting type. 
H/o decreased urine output since 1week.

No h/o of chest pain, cough, expectoration , hemoptysis, reccurent respiratory tract infections 

 No h/o palpitations, syncope, fever.

No h/o burning micturition , hematuria 
No history suggestive of hypo or hyperthyroidism 

Past history :: 
no similar complaints in the past 
known case of Hypertension since 4yrs( diagnosed when went to local rmp) and diabetes since 2yrs and is on regular medication.
Not a known case of asthma, tuberculosis and epilepsy. 
The patient is on dialysis maintenance since 1 year 

Personal history :   
-consumes mixed diet 
-Normal appetite
-sleep-adequate
-Bowel and bladder are regular 
-He is a chronic alcoholic consumes 90 ml per day since 11yrs 
-No habit of smoking and tobacco and Pan chewing 

Family history:: 
No similar illness in the family 
Lower socioeconomic status 
no significant family history  
Treatment history :: medication for diabetics mellitus since 2yrs and hypertension since 4yrs 


General examination :
patient is conscious, coherent, cooperative , oriented to time place person comfortably lying on bed 
 moderately built and nourished.
 
pallor present 



edema present 



No signs of icterus cyanosis clubbing koilonychia ,generalised lymphadenopathy,

JVP- raised 




VITALS pulse 78 /min no radio radial delay and radiofemoral dealy 

Blood pressure 150 /90 mmHg right arm supine position 
No significant postural fall 

Respiratory rate 20 cycles per minute 

Temperature afebrile 

Local examination of cardiovascular system ::
 
Inspection : 
 shape of the chest normal , symmetrical ,no deformity 
Trachea appear to be central ,no precordial bulge 
No visible impulses scars sinuses dilated veins in any part of the thorax 

Palpation : all inspectory findings confirmed by palpation   
Trachea is central 
Apex beat is felt in 6th intercostal space 
No palpable heart sounds and murmurs 
No palpable pericardial rub 

Percussion :  
Dull note is heard along the heart borders  

 Auscultation : S1 S2 heard no murmurs

Respiratory system ::bilateral air entry present 
Normal vesicular breath sounds heard no added sounds 

Per abdomen :soft ,non tender, no organomegaly ,no free fluid 
Bowel sounds heard 
Hernial orifices are normal 

CNS:: NO FOCAL NEUROLOGICAL DEFICIT 


INVESTIGATIONS 

HEMOGRAM : hemoglobin reduced 


Complete urine examination proteinuria present albumin present 4+ sugar present in urine 





Renal function test urea and creatinine raised 



 
Liver function test 





ECG 

12 leaded ecg
Heart rate : 74bpm
Normal QR segment  
Normal PR segment 

Lead II normal 
P wave 
Qrs complex 
ST segment 
T wave 


RR INTERVAL V1 to V6 for hypertrophy 
R wave is normal and progressive indicating no damage to coronary vessels and normal filling 

Chest x ray ::  






Ultrasound report. Renal parenchymal disease grade II 






Provisional diagnosis :: heart failure secondary to chronic kidney disease   

 Analysis : heart failure due to fluid over load due to chronic kidney disease ,etiology is due to chronic hypertension and diabetes 

Treatment history ::     

TREATMENT: 



SALT AND FLUID RESTRICTION

TAB. NICARDIA 10MG T.I.D

TAB. LASIX 40MG B.D

TAB. ARKAMIN 100MG

TAB. UNIFER

CAPSULE. GEL CAL D3  



46 yrs old male patient, labourer by occupation who is a k/c/o hypertension since 4 yrs, diabetic since 2 yrs and on dialysis maintainance since 1 yr came to the opd with chief complaints of shortness of breath , bilateral pedal edema and decreased urine output since 1week pitting type and with
H/o decreased urine output.
O/E pallor and edema present
Jvp is raised Apex beat felt at 6th intercostal space palpable P2 
Investigations findings:
1)Complete urine examination proteinuria present albumin present 4+ sugar present in urine
2)Renal function test urea and creatinine raised
3) Ecg:appears to be normal 
4)Ultrasound report.  
Renal parenchymal disease grade II

Provisional diagnosis:
heart failure secondary to chronic kidney disease

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